StimPad® TENS Prescription Reimbursement Application

We are happy to be of service and provide Drug Free Pain Relief™ as quickly as possible and, depending on your insurance coverage, with as little to no cost directly out of your pocket.  In the United States, the FDA mandates that these types of devices be sold under prescription from a physician / practitioner licensed in your state.  In order for us to process your Medicare / Insurance Reimbursement purchase of the StimPad® TENS and associated products, regulations also require that you grant AEMED and its assigns the right to contact you about these transactions and thereby work on your behalf to expedite the prescription and billing processes.
 

Patient Contact Waiver

By signature below, on the date specified, AEMED, or its assigns, is hereby granted the right to contact me reference prescription, billing, payment(s) on the StimPad® TENS device and associated equipment.

I understand that the information provided herein is strictly confidential and solely for use in the transaction referenced herein and for the purpose of regulatory and quality control of AEMED. Personal information shall not be disseminated to any third parties, whatsoever
 

Patient Information / Assignment of Benefits

I request that payment of authorized Medicare and/or other Insurance benefits be made either to me or on my behalf for any services furnished me, including physician services.  I hereby authorize any holder of medical or other information about me to release to the CMS and/or other insurance carriers and its agents any information needed to determine these benefits for related services.

Primary Insurance Information

Secondary Insurance Information

Signature + Date + Submit